2020 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Anthem MediBlue Access Basic (Regional PPO) (R4487-001-0) Benefit Details | ||||||
This plan is available in Statewide County, IN Monthly Premium: $29.80 Rx Deductible: $100 Initial Coverage Limit: $4,020 Click on a letter below to view the Anthem MediBlue Access Basic (Regional PPO) Formulary A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0-9 | ||||||
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
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Preferred Pharmacy | Standard Pharmacy | Mail- Order* | Preferred Pharmacy | Standard Pharmacy | Mail- Order* | |
Initial Deductible Phase Cost Sharing | ||||||
Tier 1: : | $6.00(E) | $11.00(E) | $6.00(E) | $18.00(E) | $33.00(E) | $12.00(E) |
Tier 2: : | $15.00(E) | $20.00(E) | $15.00(E) | $45.00(E) | $60.00(E) | $30.00(E) |
Tier 3: : | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 4: : | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 5: : | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 6: : | $0.00(E) | $0.00(E) | $0.00(E) | $0.00(E) | $0.00(E) | $0.00(E) |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: : | $6.00 | $11.00 | $6.00 | $18.00 | $33.00 | $12.00 |
Tier 2: : | $15.00 | $20.00 | $15.00 | $45.00 | $60.00 | $30.00 |
Tier 3: : | $42.00 | $47.00 | $42.00 | $126.00 | $141.00 | $84.00 |
Tier 4: : | 46% | 47% | 46% | 46% | 47% | 46% |
Tier 5: : | 31% | 31% | 31% | n/a | n/a | n/a |
Tier 6: : | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Coverage Gap (Donut Hole) Phase Cost Sharing 75% Generic and 75% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap | ||||||
Tier 6: : | $0.00(A) | $0.00(A) | $0.00(A) | $0.00(A) | $0.00(A) | $0.00(A) |
All Formulary Generic Drugs: | 25% | 25% | 25% | 25% | 25% | 25% |
All Formulary Brand-Name Drugs: | 25% | 25% | 25% | 25% | 25% | 25% |
Catastrophic Coverage Phase Cost Sharing | ||||||
Generic & Preferred Multi-Source Drugs: | The greater of 5% or $3.60 | The greater of 5% or $3.60 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $8.95 | The greater of 5% or $8.95 | ||||
Notes: *The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing. (E) Drugs on this tier are excluded from the Initial Deductible and do not count toward meeting the deductible. (A) Coverage Gap cost-sharing applies to all drugs on the designated tier. Drugs that are covered in the coverage gap also receive the donut hole discount. (P) Coverage Gap cost-sharing applies to only some of drugs on the designated drug tier. Drugs that are covered in the coverage gap also receive the donut hole discount. | ||||||
Go to the Anthem MediBlue Access Basic (Regional PPO) 2020 Formulary Browser by choosing a letter below: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0-9 |